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Conceived and designed the experiments: GZ SK HWV DW. Performed the experiments: SK VLP APTdR. Analyzed the data: GZ SK. Contributed reagents/materials/analysis tools: GZ ZC SC RBT HG. Wrote the manuscript: GZ DW RBT. Designed the software used in analysis: GZ. Obtained permission for use of cell line: RBT.
Quick and accurate identification of microbial pathogens is essential for both diagnosis and response to emerging infectious diseases. The advent of next-generation sequencing technology offers an unprecedented platform for rapid sequencing-based identification of novel viruses. We have developed a customized bioinformatics data analysis pipeline, VirusHunter, for the analysis of Roche/454 and other long read Next generation sequencing platform data. To illustrate the utility of VirusHunter, we performed Roche/454 GS FLX titanium sequencing on two unclassified virus isolates from the World Reference Center for Emerging Viruses and Arboviruses (WRCEVA). VirusHunter identified sequences derived from a novel bunyavirus and a novel reovirus in the two samples respectively. Further sequence analysis demonstrated that the viruses were novel members of the Phlebovirus and Orbivirus genera. Both Phlebovirus and Orbivirus genera include many economic important viruses or serious human pathogens.
Quick and accurate identification of microbial pathogens is essential for both diagnosis and response to emerging infectious diseases. High-throughput sequencing has recently emerged as a powerful approach to identify both known and novel viruses in clinical specimens. For example, high throughput Sanger sequencing combined with bioinformatic analysis lead to the discovery of human bocavirus , KI polyomavirus  and WU polyomavirus . With the advent of next-generation sequencing (NGS) technology, the increase in sequencing capability has greatly facilitated efforts to identify viruses in clinical specimens. Many novel viruses have been detected in human specimens, such as Merkel polyomavirus , astrovirus VA1  and Lujo virus . Currently, the recognition that sequences are derived from a novel virus is dependent primarily upon detecting sequence similarity between a given read and known reference sequences in various databases. Because longer nucleotide sequence reads can be translated into longer amino acid sequences, they provide a higher probability of detecting divergent sequences distantly related to known viruses. In the past few years, the majority of viruses identified by Next Generation sequencing have utilized Roche/454 platform due to the longer read length compared to Illumina or SOLiD platforms. NGS instruments are now available in most research institutions and the dramatic reduction in sequencing costs has made experimental NGS broadly accessible. However the computational analysis required to identify viral sequences within the massive volumes of data generated by NGS is a barrier for many researchers. To address this limitation, we have developed a robust computational pipeline, VirusHunter, for analysis of NGS data that is suitable for detection of both novel and known virus sequences. Beta versions of VirusHunter have been used to identify both known and novel viruses from a wide array of specimen types [5,7–13]. VirusHunter is freely available from http://www.ibridgenetwork.org/wustl/virushunter .
The World Reference Center for Emerging Viruses and Arboviruses (WRCEVA) maintains a large collection of virus isolates and provides reagents and support for investigations of virus outbreaks throughout the world . This NIAID-funded program also identifies and characterizes arboviruses (arthropod-borne viruses) and other suspected emerging viruses. The repository within the WRCEVA stores over 6000 classified arthropod-borne, rodent-borne, and other zoonotic and human viruses. In addition there are many virus samples in the collection that have not been well characterized or classified.
Salanga virus (strain AnB 904a) was originally isolated from a rodent (Aethomys medicatus) collected in 1971 in Salanga, Central African Republic  by researchers at the Institute Pasteur, Bangui, CAR. Initial analyses determined that it was chloroform-sensitive, but it did not react with any of their reagents to known African arboviruses. The virus was then sent to the Institute Pasteur, Dakar, Senegal and subsequently sent to the WRCEVA for further characterization. An early ultrastructural study by El Mekki et al. suggested that Salanga AnB 904a was a Poxvirus . Currently there are two listings of Salanga virus in the International Committee on Taxonomy of Viruses (ICTV) database. One is an unassigned species in the Bunyaviridae (acronym SGAV) while the other is an unassigned species in the Poxviridae (acronym SGV) . However, since no genome sequence is available; no definitive conclusion can be made about the taxonomic classification of Salanga virus and whether there may be two distinct viruses that currently share the same name.
KY-663 virus was originally isolated on July 18th, 1965 from the blood of a bat (Myotis macrodactylus) collected in a mine at Heramatsu, Kagoshima, Japan. The initial isolation was made by intracerebral inoculation of newborn mice. KY-663 virus was found to be partially resistant to treatment with sodium deoxycholate and did not produce a hemagglutinin. Intracranial inoculation of KY-663 into suckling mice causes lethality in 4-5 days, but it is not pathogenic to adult mice . After efforts to identify the virus in Japan were unsuccessful, it was sent to the WRCEVA for further study, but the virus remained unclassified.
In order to identify and taxonomically classify these two viruses, we used NGS technology to obtain the genomic sequences of those viruses and our customized bioinformatics pipeline, VirusHunter, to analyze the sequences. Furthermore, traditional virologic methods, including electron microscopy and serology, were also employed to provide additional modes of characterization of these viruses. Based on these analyses, Salanga virus was classified as a novel member of the Phlebovirus genus in the Bunyaviridae while KY-663 was determined to be a novel member of the Orbivirus genus in the Reoviridae. We tentatively named KY-663 Heramatsu virus (HERMV) in this manuscript.
In ultrathin sections of Vero E6 cells infected with Salanga virus, particles ~85 nm in diameter were found either inside cytoplasmic vacuoles containing usually one particle each, or at the cell surface (Figure 1A). They had morphology typical for Bunyaviridae. In BHK (baby hamster kidney) cells infected with Heramatsu, virus groups of particles ~55 nm in diameter with dense core typical for Reoviridae were found either in host cell cytosol or inside membrane-bound vacuoles (Figure 1B).
Table 1 and Table 2 show the results of complement fixation (CF) and hemagglutination inhibition (HI) tests with Salanga and 6 other selected phlebovirus antibodies and antigens. By CF test, Salanga was distinct from the other 6 viruses; but by HI test the Salanga antibody reacted with each of the other phlebovirus antigens. Although we were unable to produce a hemagglutinin with the Salanga mouse brain antigen to determine the homologous antibody titer, the results nonetheless indicate that Salanga is a phlebovirus and probably a member of Sandfly fever group.
DNA and RNA were extracted separately from Vero cells that had been inoculated with Salanga virus infected newborn mouse brain homogenate. Total nucleic acid was extracted from Heramatsu virus infected BHK cell culture supernatant and cell lysate independently. Each sample was subjected to reverse-transcription to enable subsequent detection of both RNA and DNA viruses. Following random PCR amplification, the samples were pooled (with barcodes) and then sequenced on the 454 FLX Titanium platform. 20,893 and 8,042 total reads were obtained from Salanga virus DNA and RNA sample preparation respectively. The cell lysate and fluid of Heramatsu virus cell culture were sequenced independently yielding 19,379 and 30,116 reads respectively.
We used a customized data analysis pipeline, VirusHunter, to identify viral sequences from the raw sequences of each sample. VirusHunter classifies each sequence based on the best BLAST similarity to sequences in reference databases (Figure 2, details see materials and methods). A detailed summary of the results of each step of VirusHunter is available in Files S1, S2 and S3. To give one specific illustration, for the Salanga virus RNA, 8042 total reads were collapsed by CD-HIT  (parameters 95% identity over 95% of the length) to 2924 unique sequences. Following repeatmasker analysis 861 reads were removed and 2063 “good sequences” were retained. 1697 of these reads mapped to mammalian genomes. Following the serial BLAST analyses, 144 unique viral sequences that shared 28.6-88.9% sequence identity to viruses in the genus Phlebovirus of the family Bunyaviridae were identified. No viral sequence was identified from the DNA sample of Salanga virus. From sequencing of total nucleic acid extracted from the cell lysate and fluid of Heramatsu virus cultured in BHK cells, VirusHunter identified 234 and 186 unique viral reads that shared 28.8-86.1% sequence identity to viruses of the Orbivirus genus in the family Reoviridae.
The family Bunyaviridae includes five genera of enveloped, negative-stranded RNA viruses: Orthobunyavirus, Hantavirus, Nairovirus, Phlebovirus and Tospovirus. Except tospoviruses which infect plants, the other viruses in the family infect vertebrates, and they include multiple causative agents of haemorrhagic fever such as Crimean-Congo hemorrhagic fever virus (CCHFV), Ngari virus (NRIV), Hantaan (HTNV) and Rift Valley fever virus (RVFV). Most viruses in the Bunyaviridae family are carried and transmitted by arthropods (e.g., mosquitoes, ticks, and other insects). Many bunyaviruses are classified as emerging pathogens due to their recent increased incidence in new vertebrate hosts and in new geographical locations. Bunyavirus genomes contain three negative-sense, single-stranded RNA segments, designated as large (L), medium (M), and small (S) segment.
We used all individual reads with detectable similarity to bunyaviruses as well as all sequences that did not share detectable sequence similarity with any sequence in Genbank databases as inputs for assembly using the Newbler assembler. Four contigs of length 555-3853 bp were identified. These contigs were most closely related to Durania virus, Ariquemes virus, Leticia virus (Phlebovirus sp. Co Ar 171616) and Sandfly fever sicilian virus with 61.0, 44.3, 51.7 and 26.3% aa identity respectively. Of the 4 contigs, 2 mapped to the L segment, 1 mapped to the M segment and 1 mapped to the S segment.
Using RT-PCR amplification followed by Sanger sequencing we closed the gap between the two initial L segment contigs. Additional RACE (Rapid Amplification of cDNA Ends) reactions extended the initial contigs and yielded final contigs of length 6513 bp (L segment), 4412 bp (M segment) and 1795 bp (S segment). Over-lapping RT-PCR amplification and Sanger sequencing were employed to confirm the sequences with at least 2 fold coverage for L segment nucleotide 174-6225, M segment nucleotide 280 - 4312 and the S segment nucleotide 51-1675. Using standard gene prediction tools, open reading frames were predicted in each segment. No further effort was made to completely sequence the 5’ or 3’ termini of the viral genome segments.
We obtained 6513 bp of the Salanga virus L segment (Table 3). A single open reading frame of 2123 aa was predicted. The predicted ORF was most closely related to the polymerase of Arbia virus (NR database dated February 11, 2012), a Salehabad species group virus in the Phlebovirus genus , with 59% aa identity (e value of 0.0E+00). This is consistent with the genome structure of all other bunyaviruses in which the L segments encode a single protein -- the viral RNA-dependent RNA polymerase (RdRp). The RdRp is a multifunctional protein that is responsible for the generation of RNA-replication and mRNA-transcription products from their respective viral templates.
We obtained 4412 bp of the Salanga virus M segment and a single open reading frame of 1398 aa was predicted. The predicted ORF was most closely related to the polyprotein of Arbia virus (NR database dated February 11, 2012), with 40% aa identity (e value of 0.0E+00). The M segment of all bunyaviruses encodes the glycoprotein precursor which is subsequently processed to yield two glycoproteins, Gn and Gc. However, the M segments of orthobunyaviruses, phleboviruses and tospoviruses encode an additional protein, the nonstructural protein NSm. The NSm protein is an integral membrane protein localized in the Golgi complex and it is important for virus assembly and morphogenesis . Interestingly, the location of the NSm coding region differs by genera. The NSm protein of orthobunyaviruses is encoded between the Gn and Gc proteins whereas the NSm protein of phleboviruses is N-terminal of both Gn and Gc proteins (at the 3' end of the negative sense genomic RNA). The Salanga virus M segment was predicted to encode a NSm protein at the 3' end of the viral RNA, consistent with the location observed in phleboviruses (Figure 3).
We obtained 1795 bp of the Salanga virus S segment. Two open reading frames of 269 and 245 aa were predicted. One ORF was predicted on the negative sense genomic strand while the other was encoded on the anti-genomic strand. The predicted ORF positioned at the 5’ end of the genomic strand was most closely related to the nonstructural protein (NSs) encoded in the S segment of Durania virus, an Aguacate group phlebovirus , with 26% aa identity (e value of 7.0E-15, NR database dated Nov. 12, 2012). The predicted ORF at the 3’ end of the genomic strand was most closely related to the nucleocapsid (N) protein of Leticia virus, a Punta Toro group phlebovirus, with 52% aa identify (e value of 1.0E-89, NR database dated Nov. 12, 2012). The S segments of all bunyaviruses encode the protein N whose primary role is to encapsidate the viral RNA-replication products to form the ribonucleoprotein complex. The protein N is always encoded in the anti-genomic strand. The S segments of orthobunyavirus, phlebovirus and tospovirus also encode a nonstructural protein called NSs whose primary role is modulating the host-cell antiviral response through diverse innate-immunity pathways. NSs is encoded in the anti-genomic strand in orthobunyaviruses but in the genomic strand in phleboviruses and tospoviruses. These coding strategies are generally conserved and aid in bunyavirus classification. This is consistent with its classification as a phlebovirus.
We performed phylogenetic analysis using the RNA-dependent RNA polymerase protein sequence of Salanga virus encoded on the L Segment and representative members of the Phlebovirus genus within the Bunyaviridae family. Both Neighbor-joining and maximum parsimony trees (Figure 3) of the amino acid sequence yielded the same tree topology and demonstrated that Salanga virus was most closely related to, but highly divergent from, the viruses in the Phlebovirus genus. Therefore Salanga virus should be classified as a new species within the Phlebovirus genus in the Bunyaviridae family.
The family Reoviridae contains 15 genera that differ substantially in genetic, structural and biological properties. The Orbivirus genus contains 22 serogroups (species) and at least 160 different serotypes (strains) . The orbiviruses have genomes consisting of 10 distinct segments of linear double-stranded RNA (dsRNA) that encode seven structural and at least three non-structural proteins. Bluetongue virus (BTV), the type species of the genus has 26 recognized serotypes, and African horse sickness virus (AHSV) which has 9 serotypes are the most economically important members of this genus. Orbiviruses are transmitted to animals primarily by arthropod vectors, including Culicoides midges, mosquitoes, black flies, sandflies, or ticks. Arthropod-transmitted viruses are important causes of disease in humans and animals, and it has been proposed that climate change will alter the distribution and severity of BTV infection and of other arboviral diseases .
To obtain the best genome assembly, all sequences with detectable similarity to orbiviruses as well as all sequences that did not share detectable similarity with any sequence in the databases were pooled together and assembled using Newbler assembler. Assembled contigs were compared with NCBI nr database (downloaded on January 25th, 2012) using BLASTx to identify all viral contigs. Fourteen putative viral contigs with length 131-3835 bp were identified that were most closely related to orbiviruses. The contigs shared 26.7- 71.2 % aa identity to Chuzan virus, AHSV, or BTV, each of which belongs to the Orbivirus genus of the Reoviridae. Chuzan, also known as Kasba virus, is a strain (serotype) of Palyam virus.
The 14 contigs generated from Heramatsu virus were mapped to reference orbivirus genome segments using BLAST and annotated. 13 of the 14 Heramatsu virus contigs showed significant sequence similarity to BTV genomic segments. One of the contigs did not have any detectable similarity to any BTV sequence; rather it possessed highest sequence similarity to the segment 2 of Chuzan virus with 27% aa identity over a 187 aa stretch (e value of 6E-07). Segment 2 of Chuzan virus encodes the outer capsid protein VP2. Reassortment of genome segments can contribute to virus diversity and is known to occur in orbiviruses ; the distinct relationship of segment 2 may be the result of reassortment. The RNA segment name, encoded protein as well as putative function were assigned according to the nomenclature of the Orbivirus type species BTV (Table 4) following recommended rules .
Orbivirus genomes consist of 10 RNA segments. For most of the Heramatsu virus segments, single contigs were assembled that were approximately the same size the corresponding segment of the most closely related orbivirus in Genbank. The exceptions to this were segment 3 for which we obtained four contigs of length 869, 428, 260 and 886 bp and segment 9 for which we had two contigs of length 131 and 606 bp. These gaps were closed by PCR followed by Sanger sequencing of the cloned PCR amplicons. For segment 3, a final contig of 2603 nt was generated. Overlapping RT-PCR amplification and Sanger sequencing were employed to sequence the segment 3 contig nucleotide 21-2559 with at least 2-fold coverage. For segment 9 a final contig of 738 bp was obtained, of which nucleotides 8-723 were confirmed with at least 2-fold coverage. While these contigs did not represent the complete sequences of the genome segments, they sufficed for taxonomic classification and thus no effort was made to obtain the terminal sequences of any of the segments.
To understand the relationship of Heramatsu virus to other orbiviruses we performed phylogenetic analysis using the RNA-dependent RNA polymerase protein sequence of Heramatsu virus encoded on Segment 1 and representative members of the Orbivirus genus within the Reoviridae family. Both Neighbor-joining and maximum parsimony trees (Figure 4) of the amino acid sequence yielded the same tree topology and demonstrated that Heramatsu virus is most closely related to, but highly divergent from, the viruses in the Orbivirus genus. According to previously published criteria, RNA polymerase sequences of viruses belonging to a single genus within the family Reoviridae share >30% amino acid sequence identity . Based on this criterion, Heramatsu virus should be classified as an Orbivirus.
We utilized a combination of traditional virology methods, such as electron microscopy and serological analysis, and NGS sequencing with subsequent bioinformatics analysis using VirusHunter, to identify and taxonomically classify two previously isolated, but poorly characterized, viruses from the WRCEVA collection. Sequence analysis demonstrated that the viruses were highly divergent from previously described viruses. Salanga virus was classified as a novel member of the Phlebovirus genus in the Bunyaviridae while Heramatsu virus was determined to be a novel member of the Orbivirus genus in the Reoviridae. Both the Orbivirus and Phlebovirus genera include many economic important viruses or serious human pathogens. The sequencing and classification of these two viruses will be a valuable addition to studies of arboviruses and emerging viruses.
Salanga virus (strain AnB 904a) was originally isolated from a rodent (Aethomys medicatus) collected in September 1971 at Salanga, Central African Republic. The Heramatsu virus (strain KY-663) used in this study was originally isolated from the blood of a bat (Myotis macrodactylus) collected in a mine at Heramatsu, Kagoshima, Japan in July 18th, 1965.
For ultrastructural analysis in ultrathin sections, infected Vero or BHK cells were fixed for at least 1 h in a mixture of 2.5% formaldehyde prepared from paraformaldehyde powder, and 0.1% glutaraldehyde in 0.05 M cacodylate buffer pH 7.3 to which 0.03% picric acid and 0.03% CaCl2 were added. The monolayers were washed in 0.1 M cacodylate buffer, cells were scraped off and processed further as a pellet. The pellets were post-fixed in 1% OsO4 in 0.1 M cacodylate buffer pH 7.3 for 1 h, washed with distilled water and en bloc stained with 2% aqueous uranyl acetate for 20 min at 60°C. The pellets were dehydrated in ethanol, processed through propylene oxide and embedded in Poly/Bed 812 (Polysciences, Warrington, PA). Ultrathin sections were cut on Leica EM UC7 ultramicrotome (Leica Microsystems, Buffalo Grove, IL), stained with lead citrate and examined in a Philips 201 transmission electron microscope at 60 kV.
Antigens used in serologic tests were infected newborn mouse brains prepared by the sucrose/acetone extraction method . Specific hyperimmune mouse ascitic fluids were prepared at the WRCEVA against each of the viruses used in this study. The immunization schedule consisted of four intraperitoneal injections given at weekly intervals. Immunogens were 10% suspensions of homogenized infected mouse brain in PBS, mixed with Freund’s adjuvant just prior to inoculation. Sarcoma 180 cells were also given intraperitoneally with the final immunization in order to induce ascites formation. All animal experiments were carried out under an animal protocol approved by the University of Texas Medical Branch IACUC committee.
Hemagglutination inhibition (HI) tests were done in microtiter plates, as previously described , using four units of antigen. The HI titer was read after overnight incubation of antigen and antibody at 4°C. Complement-fixation (CF) tests were performed by the microtiter technique , using two units of guinea pig complement and overnight incubation of the antigen and antibody at 4°C. The CF titers were recorded as the highest dilutions giving 3+ or 4+ fixation of complement on a scale of 0 to 4+.
Total nucleic acid was extracted from Heramatsu virus infected BHK cell culture supernatant and cell lysate independently with a Qiagen DNeasy kit according to the manufacturer’s instructions. DNA and RNA were extracted from Salanga virus infected culture of Vero E6 cells cell separately. Both cell lines were obtained from the American Type Culture Collection (Manassas, VA).
Nucleic acid from each sample was reverse-transcribed to enable subsequent detection of both RNA and DNA viruses and was amplified as previously described [29,30]. Amplification products were pooled, adaptor-ligated and sequenced at the Washington University Genome Sequencing Center on the 454 GS-FLX platform (454 Life Sciences). Sequences were then trimmed to remove primer B sequences prior to assembly using the Newbler program (454 Life Sciences, Branford, CT).
Because the nucleic acid used for sequencing contained a mixture of host cell DNA and virus RNA, we used a customized informatics pipeline VirusHunter to identify viral sequences. The VirusHunter pipeline is controlled by a master Perl script VirusHunter.pl, which executes each step in the pipeline. The input to the pipeline is a directory path. The directory holds sequencing data from different samples. Each sample has its own directory with a single file containing FASTA format sequence reads.
The workflow of the pipeline is shown in Figure 2. Below is a brief description of each step.
The final output of the VirusHunter pipeline is a single file summarizing all the viruses identified in each dataset in the input directory. The pipeline can be customized to generate similar outputs for other bacterial, fungal or parasitic sequences.
VirusHunter is written in Perl. It uses shell scripting, the BioPerl library, MySQL database, CD-HIT, RepeatMasker and NCBI BLAST suite. The pipeline is fully automated and high-throughput. All components are organized in a hierarchical set of readily modifiable scripts, and multiple copies of the pipeline can be run in parallel. The pipeline is designed for running on a high performance computing cluster using GridEngine as the job scheduler. It can be easily modified to use other job management software. The pipeline can be easily customized, for example to replace the human genome database with that of a different host. Installation and configuration of VirusHunter requires basic knowledge of Perl, MySQL database and Linux system administration. Distribution and source code for VirusHunter 1.0 are available at (http://www.ibridgenetwork.org/wustl/virushunter).
Sequences identified as viral as well as sequences that had no significant hit to any sequence in the NR and NT databases were assembled using Newbler (454 Life Sciences, Branford, CT) with default parameters. ORFs were predicted and annotated using Artemis . Multiple sequence alignments were performed with ClustalW . Phylogenetic analysis was performed using both neighbor-joining method and maximum parsimony method in MEGA5 program  with 1000 bootstrap replicates. Trees with the same topology were generated using both methods for all the data sets used in the study. Phylogenetic trees were visualized using TreeView .
The viruses analyzed included the following genera, species, and strains:
Aguacate virus (AGUV, YP_004414703.1), Arbia virus (ARBV, AGA82737.1), Arumowot virus (AMTV, AEF30501.1), Durania virus (DURV, AEB70976.1), Leticia virus (AEL29649.1, also named Phlebovirus CoAr 171616), Odrenisrou virus (ODRV, AEL29670.1), Rift Valley fever virus (RVFV, YP_003848704.1), Rift Valley fever virus (RVFV_ABD51499.1, ABD51499.1), Salehabad virus (SALV, AGA82741.1), Toscana virus (TOSV, CAA48478.1), Uukuniemi virus (UUKV, BAA01590.1).
African horsesickness virus serotype 1 (AHSV-1, CAP04840.1), African horsesickness virus serotype 9 (AHSV-9, AAC40586.1), Bluetongue virus Serotype 10 (BTV-10, YP_052968.1), Bluetongue virus Serotype 12 (BTV-12, AGJ83521.1), Chuzan virus (CHUV, BAA76549.1), Epizootic hemorrhagic disease virus serotype 1 / strain New Jersey (EHDV-1, YP_003240108.1), Epizootic hemorrhagic disease virus serotype 7 / strain CSIRO 775 (EHDV-7, CAN99553.1), Great Island virus (GIV, YP_003896058.1). St Croix River virus (SCRV, YP_052942.1), Yunnan orbivirus (YUOV, YP_443925.1).
The sequence of the Salanga virus and Heramatsu Orbivirus (HERMV) KY-663 genomic fragments has been deposited in the NCBI database under GenBank accession number KC669549 - KC669551 and KC669539 - KC669548 respectively. Raw data is deposited in the Sequence Read Archive (SRA) under accession number SRR959764.
VirusHunter summary output file of the Salanga virus RNA sequencing data.
VirusHunter summary output file of the Heramatsu Orbivirus (HERMV) KY-663 cell culture lysate sequencing data.
VirusHunter summary output file of the Heramatsu Orbivirus (HERMV) KY-663 cell culture fluid sequencing data.
The authors thank Kevin Chen for his effort in testing the software package and his thoughtful comments.
This work was supported by the National Institutes of Health Midwest Regional Center of Excellence for Biodefense and Emerging Infectious Diseases Research [U54 AI057160] and by NIAID contract HHSN27220100004OI/HHSN27200004. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.